Chronic Pain

Noble Savage

Noble Savage

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aychamo_aycono_sl said:
I'm sorry to hear about your diagnosis. Please ignore most of the advice you've received here (meditation, physical therapy referral, etc), as it's all wrong..
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When I was working in a physical therapy clinic awaiting the start of graduate school, we had a number of patients referred to us by Doctors who were suffering from TMJ. Some saw relief and were able to manage their pain, others didn't. And there are a number of research studies that demonstrate that PT can be an effective tool in the management of TMJ pain.

http://www.ncbi.nlm.nih.gov/pubmed/23229236
http://www.ncbi.nlm.nih.gov/pubmed/17086858
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813497/
etc. etc. etc.


Of course TMJ is a complicated issue so what works for one person won't work for another, and it is also possible the Doctor missed something in his diagnosis. But saying PT is "wrong" is disingenuous because Doctors do refer their TMJ patients to physical therapy clinics and some of them do see relief.
 
Cybsled

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Under what circumstances have you seen these "plenty of cases," especially post-mortem?
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Well, they've all been post-mortem. In one case, it was discovered that while the person died primarily of a recent stroke/brain hemorrhage, they found that the person had evidence of previous instances of this, although they couldn't date when this happened and there was no clinical records recording this happening in the past. But you're right in that most cases I've seen where a person died of a stroke, but had a past history of similar events, usually said event was clinically recorded in the past.
 
Aychamo BanBan

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The Noble Savage_sl said:
http://www.ncbi.nlm.nih.gov/pubmed/23229236
http://www.ncbi.nlm.nih.gov/pubmed/17086858
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813497/
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First study was extraordinarily small, and compared anesthesia to anesthesia + PT. Virtually useless study. Second study had no control group, etc, just a poor questionnaire with mixed treatment modalities. Third article isn't a study. It's pretty clear there is no compelling evidence that PT has any clinically meaningful effect on TMJ. Regardless, OP does not have TMJ, but TN.
 
Aychamo BanBan

Aychamo BanBan

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Cybsled_sl said:
Well, they've all been post-mortem. In one case, it was discovered that while the person died primarily of a recent stroke/brain hemorrhage, they found that the person had evidence of previous instances of this, although they couldn't date when this happened and there was no clinical records recording this happening in the past. But you're right in that most cases I've seen where a person died of a stroke, but had a past history of similar events, usually said event was clinically recorded in the past.
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I'm not trying to be argumentative. But if you're seeing infarction post-mortem, that's a stroke. Hemorrhage could be a number of things, but all of which would have symptoms greater than chronic headache. A brain bleed is a neurosurgical emergency that requires immediate intervention. Bottom line, unilateral exquisite facial pain in the distribution of the trigeminal nerve associated with headache does not make one think of cerebrovascular compromise.
 
Azrayne

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Only problem is that you're acting on the assumption that it's a 100% certainty that he has Trigeminal Neuralgia. From the way he described his interactions with his doctor it hardly sounds like the diagnosis is set in stone, he doesn't sound too confident about it, and from the way he tells it, it doesn't sound like his doctor is either. This isn't something backed up by a bunch of MRI's and blood tests, just a bunch of symptoms which are trying to be matched up correctly (and with the diagnosis already having been changed at least once), in which case I'd think it more than sensible that he take as broad an approach to treatment as possible, within reason.
 
Saladus

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Sorry for not responding sooner, I've been so busy moving everything and doing work in the new house. As far as questions about CT scan... I had an MRI done in July I believe to check for issues, no CT scan (not sure if there's a difference), and they said they saw no issues. Of course, I assume with saying it may be TN that they have to focus closer on other areas.

Azrayne is correct with the last statement... I gave the symptoms, which at the time didn't even include shocks, and she simply seemed to match it with what it seemed to fall into. Since then it seems to be getting worse and worse. It feels often like my face is constantly burning and my jaw has this line of painful tightness in it. I have no idea if it's from these meds or not (tegretol / carbamazepine), but since if been taking then, I get lots of tingling and burning on my right face. Tonight, for the first time while at a god damn family party of course, I had a sharp sort of jab in my right eye, felt like a shock. While things seem to be matching up lately with TN that was suggested, I'm still holding on to hope that TN is not the condition. I appreciate the condolences more than anything and am not looking for medical advice... Doctors have felt useless enough with the blanket diagnoses, and googling all then conditions out there will just make you feel lose any sleep you were hoping to get. I'll keep you all posted, as my neuro visit is Jan 3.
 
Aychamo BanBan

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Azrayne_sl said:
Only problem is that you're acting on the assumption that it's a 100% certainty that he has Trigeminal Neuralgia. From the way he described his interactions with his doctor it hardly sounds like the diagnosis is set in stone, he doesn't sound too confident about it, and from the way he tells it, it doesn't sound like his doctor is either. This isn't something backed up by a bunch of MRI's and blood tests, just a bunch of symptoms which are trying to be matched up correctly (and with the diagnosis already having been changed at least once), in which case I'd think it more than sensible that he take as broad an approach to treatment as possible, within reason.
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Interestingly, you're both right and wrong at the same time. It's called the art of medicine for a reason. Imagine this scenario. A patient comes in with pain and swelling in her right calf. An ultrasound reveals a deep venous thrombosis. Patient is admitted to the hospital and started on Lovenox (anticoagulation, to prevent further clot build up.) While bridging the patient to warfarin, she experiences the sudden onset of difficulty breathing and pain in her chest. The most likely scenario is that she threw a pulmonary embolism, but we don't know this for 100% certain. We could do a CT of her chest and expose her to radiation (which would increase the likelihood of some type of thoracic cancer by almost 0.5-1%) to prove that she has a pulmonary embolism, or we could presume she has one, because proving it would not change the course of treatment (you treat a pulmonary embolism the same way as a DVT.)

Similarly, when someone presents with unilateral facial pain in the distribution of the trigeminal nerve, you think trigeminal neuralgia and start treating for that. TN is mainly a clinical diagnosis, as there aren't any blood or imaging tests to back it up. With his symptoms, you don't think "cerebral hemorrhage" and do a CT scan of the head. You don't run every test in the book for every complaint. No medical system on planet earth could sustain itself if medicine were practiced this way. Yes, sometimes mistakes are made, but if you follow the best evidence based guidelines, then 99 times out of a 100 you're going to be ok. It's actually a big problem with doctors and mid-level providers (NPs, PAs, etc) with poor diagnostic skills that work in ERs. People will present with certain problems, and instead of being able to diagnose the problem they run every test in the book, which skyrockets the cost of healthcare and exposes people to unnecessary radiation. CT scans can cause cancer. I have one patient that has hemiplegic migraines (migraine headaches so bad that they give her stroke-like symptoms), and every time the poor girl comes into the ER she gets a CT scan of the head, because of the fear that one time she may actually be having a real stroke, but the poor girl may eventually develop brain cancer. (Note, CT of the head is the first test run on any patient with stroke to see if it's hemorrhagic or ischemic, the latter receiving aspirin and being managed medically [I don't push TPA, poor neurosurgery coverage where I am], the former of course requiring immediate neurosurgical intervention.)

Basically, you treat common problems commonly. In the case of the OP, I would have been suspicious of giant cell arteritis, which is a medical emergency, but my physical exam and the course of the disease would have led to the correct path. I probably would have gotten a biopsy of his temporal artery and checked a ESR/CRP to be safe.
 
Azrayne

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aychamo_aycono_sl said:
Interestingly, you're both right and wrong at the same time. It's called the art of medicine for a reason. Imagine this scenario. A patient comes in with pain and swelling in her right calf. An ultrasound reveals a deep venous thrombosis. Patient is admitted to the hospital and started on Lovenox (anticoagulation, to prevent further clot build up.) While bridging the patient to warfarin, she experiences the sudden onset of difficulty breathing and pain in her chest. The most likely scenario is that she threw a pulmonary embolism, but we don't know this for 100% certain. We could do a CT of her chest and expose her to radiation (which would increase the likelihood of some type of thoracic cancer by almost 0.5-1%) to prove that she has a pulmonary embolism, or we could presume she has one, because proving it would not change the course of treatment (you treat a pulmonary embolism the same way as a DVT.)

Similarly, when someone presents with unilateral facial pain in the distribution of the trigeminal nerve, you think trigeminal neuralgia and start treating for that. TN is mainly a clinical diagnosis, as there aren't any blood or imaging tests to back it up. With his symptoms, you don't think "cerebral hemorrhage" and do a CT scan of the head. You don't run every test in the book for every complaint. No medical system on planet earth could sustain itself if medicine were practiced this way. Yes, sometimes mistakes are made, but if you follow the best evidence based guidelines, then 99 times out of a 100 you're going to be ok. It's actually a big problem with doctors and mid-level providers (NPs, PAs, etc) with poor diagnostic skills that work in ERs. People will present with certain problems, and instead of being able to diagnose the problem they run every test in the book, which skyrockets the cost of healthcare and exposes people to unnecessary radiation. CT scans can cause cancer. I have one patient that has hemiplegic migraines (migraine headaches so bad that they give her stroke-like symptoms), and every time the poor girl comes into the ER she gets a CT scan of the head, because of the fear that one time she may actually be having a real stroke, but the poor girl may eventually develop brain cancer. (Note, CT of the head is the first test run on any patient with stroke to see if it's hemorrhagic or ischemic, the latter receiving aspirin and being managed medically [I don't push TPA, poor neurosurgery coverage where I am], the former of course requiring immediate neurosurgical intervention.)

Basically, you treat common problems commonly. In the case of the OP, I would have been suspicious of giant cell arteritis, which is a medical emergency, but my physical exam and the course of the disease would have led to the correct path. I probably would have gotten a biopsy of his temporal artery and checked a ESR/CRP to be safe.
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Sure, I get that, but this isn't an emergency situation, which leaves him plenty of room to move, both practically and financially, and I'd say that in this particular situation the diagnosis is a good deal less solid than your example of the DVT and the potential pulmonary embolism. And nobody is suggesting he go out and get every test and every treatment in the world simultaneously. But saying that it's straight up 'wrong' to explore any pain control measures or treatments outside of a single medication from a single diagnosis when there's quite a chance said diagnosis is wrong or that the prescribed medication won't work to the desired extent comes off as arrogant and somewhat dismissive.

In short: Racking up thousands of dollars in bills seeing every doctor and proclaimed "healer" of some kind, getting every test you can, and trying absolutely any treatment is a bad idea on a number of levels. But remaining open minded about your diagnosis until it's more set in stone and you've had a further chance to explore treatment, while pursuing (to follow up on the examples you chose) a technique well known to be helpful in both pain reduction (arguably in some situations) and psychological management of pain, and another treatment which could well make a difference if the problem turns out to be muscular or skeletal in source instead of neurological, and in the least will quite likely increase his comfort level in other ways even if he does turn out to have TN and the prescribed treatment is the only thing that works, seems to be to be not only a good idea, but common sense. (ugh, run on sentence, sorry I just woke up and my brain is mush) He could probably undergo a few sessions of meditation training with a focus on dealing with chronic pain 'and' a few months of physical therapy for less than he's already spent on doctors appointments and pills, let alone what he'll end up spending, if my understanding of the US medical system is anywhere close to accurate.
 
Aychamo BanBan

Aychamo BanBan

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This is exactly why I only ever post about having sex, masturbating, and movies. You are 100% talking out of your ass. Your suggestion that he should have undergone meditation training and physical therapy for trigeminal neuralgia is just idiotic, and only would have wasted both time and money. You would have suggested he suffer needlessly simply because you talked out of your ass. It's posts like these that make me hate the internet.

tldr; Sorry, that's just stupid.
 
Azrayne

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I didn't suggest meditation (although I don't think it's a bad idea), I suggested physical therapy, which is perfectly reasonable when someone is suffering pain without a solid diagnosis, especially on a website where everyone has almost certainly spent large chunks of time hunched in front of a screen. People like you are the reason so many people hate dealing with doctors, convinced that a few years of med school make you gods gift to the field, that you couldn't possibly be wrong about anything, despite the fact that you're not even particularly advanced in your profession and that medicine itself is a constantly evolving field with an understanding of health and the body which grows and adapts all the time. You've also probably seen a few too many episodes of House and mistake being rude, arrogant and dismissing the thoughts, feelings and opinions of those you treat and everyone else for being a talented maverick who 'says it like it is.' Boy, I bet your patients just fucking love you.

Did you miss the part where he said he wasn't even asking for medical advice? He asked for condolence and advice for dealing with chronic pain (from people with personal experience, he already has a doctor), not for Aychamo MD to swoop in and save the day over the internet while telling everyone else that they're fucking idiots.
 
Aychamo BanBan

Aychamo BanBan

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Azrayne_sl said:
I didn't suggest meditation (although I don't think it's a bad idea), I suggested physical therapy, which is perfectly reasonable when someone is suffering pain without a solid diagnosis, especially on a website where everyone has almost certainly spent large chunks of time hunched in front of a screen. People like you are the reason so many people hate dealing with doctors, convinced that a few years of med school make you gods gift to the field, that you couldn't possibly be wrong about anything, despite the fact that you're not even particularly advanced in your profession and that medicine itself is a constantly evolving field with an understanding of health and the body which grows and adapts all the time. You've also probably seen a few too many episodes of House and mistake being rude, arrogant and dismissing the thoughts, feelings and opinions of those you treat and everyone else for being a talented maverick who 'says it like it is.' Boy, I bet your patients just fucking love you.

Did you miss the part where he said he wasn't even asking for medical advice? He asked for condolence and advice for dealing with chronic pain (from people with personal experience, he already has a doctor), not for Aychamo MD to swoop in and save the day over the internet while telling everyone else that they're fucking idiots.
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I appreciate that you're insulting me simply because I pointed out that basically everything you wrote and argued was wrong. BTW, physical therapy is in no way indicated for someone suffering with unilateral trigeminal nerve pain. lol. Just quit talking out of your ass and admit you have no idea what you're talking about.

Honestly, it's rather hilarious that you are so angry with me just because I'm pointing out that what you are saying is wrong. No reasonable doctor on earth would send someone for 3 different types of pain relief "just in case" their diagnosis is wrong, especially when 1 of those ways is basically useless, and the other 1 is in no way indicated for the most likely diagnosis. Obviously doctors are (often!) wrong, but what you are suggesting is not reasonable, and it is not how medicine is practiced. Simply, it's wrong.
 
Azrayne

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I'm not insulting you because you're saying I'm wrong, I'm insulting you because you're being an asshole. And while I'm glad that you're so confident about diagnosing someone on a forum when neither he nor his doctor themselves are confident of said diagnosis (which has already been changed twice), you could sit there and say 'the best thing to do is to listen to your doctor, do what they say and do nothing but what they say,' that'd be a valid contribution to the discourse here. But you're missing the fundamental point, he has a doctor and he can go to them for the medical stuff, he came here because, if I understand what he's saying correctly, he wants support and advice from people who've had to deal with various types of chronic pain themselves, which he can't get from his doctor and he certainly isn't getting from you barging in here to pretend you're Hugh Laurie, boasting and getting off on posting journal articles which the rest of us plebs can't provide.

I do get where you're coming from though. You graduated what, 3 years ago? Less than 5, unless there was someone else congratulating themselves for graduating from med school in SS back in the day. I've dealt with enough doctors, thanks to family members and their friends/acquaintances, as well as as a patient, to know that this kind of extreme arrogance and self confidence is endemic among young doctors fresh out of med school. Maybe it's just the culture in med schools, or something in how they teach you to deal with people, or just a way of letting off stream during the stressful early years combined with the euphoria of having achieved the start of what I'm sure you hope and believe will be a successful and lucrative career. I don't know, but I do know that 90% of them grow out of it and that hopefully in 10 or 15 years you'll laugh at how over the top you were. Or maybe you're just a dick, which is a shame, but it's your life.

Of course I could be mistaken and maybe you are in that 10% who just suck, either way.
 
Aychamo BanBan

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Azrayne_sl said:
I'm not insulting you because you're saying I'm wrong, I'm insulting you because you're being an asshole. And while I'm glad that you're so confident about diagnosing someone on a forum when neither he nor his doctor themselves are confident of said diagnosis (which has already been changed twice), you could sit there and say 'the best thing to do is to listen to your doctor, do what they say and do nothing but what they say,' that'd be a valid contribution to the discourse here. But you're missing the fundamental point, he has a doctor and he can go to them for the medical stuff, he came here because, if I understand what he's saying correctly, he wants support and advice from people who've had to deal with various types of chronic pain themselves, which he can't get from his doctor and he certainly isn't getting from you barging in here to pretend you're Hugh Laurie, boasting and getting off on posting journal articles which the rest of us plebs can't provide.

I do get where you're coming from though. You graduated what, 3 years ago? Less than 5, unless there was someone else congratulating themselves for graduating from med school in SS back in the day. I've dealt with enough doctors, thanks to family members and their friends/acquaintances, as well as as a patient, to know that this kind of extreme arrogance and self confidence is endemic among young doctors fresh out of med school. Maybe it's just the culture in med schools, or something in how they teach you to deal with people, or just a way of letting off stream during the stressful early years combined with the euphoria of having achieved the start of what I'm sure you hope and believe will be a successful and lucrative career. I don't know, but I do know that 90% of them grow out of it and that hopefully in 10 or 15 years you'll laugh at how over the top you were. Or maybe you're just a dick, which is a shame, but it's your life.

Of course I could be mistaken and maybe you are in that 10% who just suck, either way.
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Lol. Learn to read. I never offered the OP any advice. In fact, I gave him exactly what he wanted, information on pain control and treatment of his condition. I copy-pasted from a highly trusted peer-reivewed source all the latest research and data on TN. I never suggested he get any other tests performed or suggested any alternative diagnosis. The only "advice" I offered was discrediting all the wrong information and suggestions he got from people here who have no idea what they are talking about (ie, just like you.)

You're just a fucking idiot. You're making an assload of assumptions solely because I pointed out that you have no idea what you are talking about. And you don't. Your suggestions to the OP were completely wrong and are against the way medicine is practiced in virtually every part of the world. God forbid you say "Damn, I was wrong, thank you for teaching me something." I'd also like you to know that no doctor models himself after House, and the TV show sucked. So you can stop with that whole belief, because it's just absolutely naive and retarded.

Sorry I have to cut this short. Off to work. I have to go be an asshole all day to my patients and pretend that I'm House and shit on everyone around me and practice evil Western Medicine. Fucking idiot.
 
Azrayne

Azrayne

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Yup, I'm a hippy who thinks western medicine is evil because I said it wouldn't be a bad idea to try out a few sessions of physical therapy if you're suffering from chronic pain with an uncertain diagnosis. And I need to learn to read apparently, despite the fact that he never once asked for:

information on pain control and treatment of his condition.
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What he did ask was:

So is there anyone here who has to live through pain day in and day out through his or her life?
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If I'd suggested some controversial or expensive or dangerous treatment, sure, you'd be absolutely right to barge in and say it's a bad idea. But it's fucking physical therapy. It's cheap, it's legitimate, it's helped a lot of people and requires absolutely no commitment beyond a little cash on a weekly basis. Do I think it's going to cure Trigeminal fucking Neuralgia? Of course not. But if his doctors are wrong for a third time it might help whatever is actually going on, and given that he's (presumably) a young guy who's at least somewhat interesting in computers and gaming in a highly inert society where it's not unusual to spent more time out of many days sitting than standing, it's hard to see how a little physical therapy could possibly do any harm. Worst case scenario is he's short some beer money for the weekend and feels weird having a dude touch his body, in which case no harm done and he can cross his fingers hoping the meds work.
 
K

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I have an uncle with TN. He uses klonopin and smokes marijuana with high CBD content + opioids to help manage it. Anticonvulsants don't help him much =/. This was after he tried to kill himself to get away from the pain.

So yeah dude, get on medication before this shit drives you crazy.
 
Aychamo BanBan

Aychamo BanBan

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Azrayne_sl said:
Yup, I'm a hippy who thinks western medicine is evil because I said it wouldn't be a bad idea to try out a few sessions of physical therapy if you're suffering from chronic pain with an uncertain diagnosis. And I need to learn to read apparently, despite the fact that he never once asked for:



What he did ask was:



If I'd suggested some controversial or expensive or dangerous treatment, sure, you'd be absolutely right to barge in and say it's a bad idea. But it's fucking physical therapy. It's cheap, it's legitimate, it's helped a lot of people and requires absolutely no commitment beyond a little cash on a weekly basis. Do I think it's going to cure Trigeminal fucking Neuralgia? Of course not. But if his doctors are wrong for a third time it might help whatever is actually going on, and given that he's (presumably) a young guy who's at least somewhat interesting in computers and gaming in a highly inert society where it's not unusual to spent more time out of many days sitting than standing, it's hard to see how a little physical therapy could possibly do any harm. Worst case scenario is he's short some beer money for the weekend and feels weird having a dude touch his body, in which case no harm done and he can cross his fingers hoping the meds work.
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Again, your suggestions are simply idiotic. I don't mean thatyouare idiotic, but thesuggestionis. Sending him to PT at this time is no way warranted, and the suggestion is honestly laughable. Especially when you're trying to tie gaming into it. Sitting all day long will give you exquisite unilateral face pain in the trigeminal nerve distribution that PT will help? What planet are you from? Your "defense" of launching a tirade against doctors saying we're all cocky idiots or whatever is nonsense. I wish you could just admit that you don't know what you are talking about instead of arguing with someone who does.
 
C

cosmic_cs_sl

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aychamo_aycono_sl said:
Again, your suggestions are simply idiotic. I don't mean thatyouare idiotic, but thesuggestionis. Sending him to PT at this time is no way warranted, and the suggestion is honestly laughable. Especially when you're trying to tie gaming into it. Sitting all day long will give you exquisite unilateral face pain in the trigeminal nerve distribution that PT will help? What planet are you from? Your "defense" of launching a tirade against doctors saying we're all cocky idiots or whatever is nonsense. I wish you could just admit that you don't know what you are talking about instead of arguing with someone who does.
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Dunno man, there were only 140 or so patients for all the carbamazepine studies (and the evidence for other treatments is poor, according to the UTD stuff you posted). That kinda asks for a more broad / person-specific approach since the evidence is lacking.

But ya, I'm not sure PT will help much with neuropathic pain.
 
Noble Savage

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I think this thread has gotten a little out of hand.

A guy creates a post seeking to commiserate with others who are unfortunate and deal with chronic incessant pain. Some people make some recommendations on things that might help said person deal with their pain; and in my limited professional capacity I had personally met and dealt with people who had been diagnosed with TMJ and subsequently referred to physical therapy for pain management. Results were mixed, as I originally stated, and in no way was it ever intended to cure the problem, it was meant to help the pain.

Perhaps the OP has an as of yet undiagnosed neurological condition, but I do know that aggravated inflamed muscles can compress nerves producing symptoms that resemble neurological conditions. And that is why I specifially said in my initial post that my suggestion was if it was TMJ and not something more severe.

But I'm not a Doctor, and even if I was I wouldn't be comfortable diagnosing someone over the internet, or even confirming a diagnosis like Aychamo seems to be confident in doing, particularly with such little history.

It was a simple recommendation to manage pain, it might help and it might not. If it doesn't work they're out 50 - 100 bucks and their Physician care was never hampered. But if it does help them, then kudos. No one suggested the poster stop seeing their Doctor, or to not continue to seek further testing to diagnosis what is actually going on. At the very least on their next Doctor visit they can ask about any of the recommendations put forth in this thread and get their Doctor's input.
 
Aychamo BanBan

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Holy shit. The OP doesn't have TMJ, did you not read what he wrote?

And how fucking ignorant are some of you to sit there and admit that you don't have a shred of professional training or even an ounce of knowledge, and yet sit there and argue with someone who does and suggest ways to treat conditions in which you know absolutely nothing about? And at that you can't even read the original post and see which condition you are offering useless treatment ideas for...

Let's do a little math here. According to Google there are over 300,000,000 people in the U.S. Let's say 1 in 300 end up at a useless physical therapy visit because some ignorant person on the internet suggested it. We'll estimate a cost of $150 for a "new patient" visit at physical therapy. But that's not all, because PT's cannot see patients off the street, they require a referral from a doctor, so that means the patient has to have a doctor's appointment first, but for the sake of simplicity we will ignore those costs. So we have 1,000,000 people all wasting $150, that comes out to $150,000,000 spent because "we should be open minded." Now who bears the cost of that? We all do - by our insurance premium costs. Or if you're Medicaid, the we all bear it too by paying taxes. That's horribly inefficient for something that is simply not indicated. That's just poorly practiced and inefficient medicine.

A lot of screening and treatment decisions for medicine is made in this way. What's the overall cost of something, and does it add enough information or clinical relevance to be worth the cost? (And things are only going to get worse thanks to a certain someone.)
 
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